{"id":27,"date":"2024-02-29T09:57:56","date_gmt":"2024-02-29T09:57:56","guid":{"rendered":"https:\/\/zuhause-umsorgt.homeinstead.de\/passt-home-instead-zu-mir\/?page_id=27"},"modified":"2024-09-26T16:32:14","modified_gmt":"2024-09-26T14:32:14","slug":"survey","status":"publish","type":"page","link":"https:\/\/zuhause-umsorgt.homeinstead.de\/dialog\/passt-home-instead-zu-mir\/survey\/","title":{"rendered":"Passt Home Instead zu mir? &#8211; Survey"},"content":{"rendered":"<script type=\"text\/javascript\">\n\/* <![CDATA[ *\/\nvar gform;gform||(document.addEventListener(\"gform_main_scripts_loaded\",function(){gform.scriptsLoaded=!0}),document.addEventListener(\"gform\/theme\/scripts_loaded\",function(){gform.themeScriptsLoaded=!0}),window.addEventListener(\"DOMContentLoaded\",function(){gform.domLoaded=!0}),gform={domLoaded:!1,scriptsLoaded:!1,themeScriptsLoaded:!1,isFormEditor:()=>\"function\"==typeof InitializeEditor,callIfLoaded:function(o){return!(!gform.domLoaded||!gform.scriptsLoaded||!gform.themeScriptsLoaded&&!gform.isFormEditor()||(gform.isFormEditor()&&console.warn(\"The use of gform.initializeOnLoaded() is deprecated in the form editor context and will be removed in Gravity Forms 3.1.\"),o(),0))},initializeOnLoaded:function(o){gform.callIfLoaded(o)||(document.addEventListener(\"gform_main_scripts_loaded\",()=>{gform.scriptsLoaded=!0,gform.callIfLoaded(o)}),document.addEventListener(\"gform\/theme\/scripts_loaded\",()=>{gform.themeScriptsLoaded=!0,gform.callIfLoaded(o)}),window.addEventListener(\"DOMContentLoaded\",()=>{gform.domLoaded=!0,gform.callIfLoaded(o)}))},hooks:{action:{},filter:{}},addAction:function(o,r,e,t){gform.addHook(\"action\",o,r,e,t)},addFilter:function(o,r,e,t){gform.addHook(\"filter\",o,r,e,t)},doAction:function(o){gform.doHook(\"action\",o,arguments)},applyFilters:function(o){return gform.doHook(\"filter\",o,arguments)},removeAction:function(o,r){gform.removeHook(\"action\",o,r)},removeFilter:function(o,r,e){gform.removeHook(\"filter\",o,r,e)},addHook:function(o,r,e,t,n){null==gform.hooks[o][r]&&(gform.hooks[o][r]=[]);var d=gform.hooks[o][r];null==n&&(n=r+\"_\"+d.length),gform.hooks[o][r].push({tag:n,callable:e,priority:t=null==t?10:t})},doHook:function(r,o,e){var t;if(e=Array.prototype.slice.call(e,1),null!=gform.hooks[r][o]&&((o=gform.hooks[r][o]).sort(function(o,r){return o.priority-r.priority}),o.forEach(function(o){\"function\"!=typeof(t=o.callable)&&(t=window[t]),\"action\"==r?t.apply(null,e):e[0]=t.apply(null,e)})),\"filter\"==r)return e[0]},removeHook:function(o,r,t,n){var e;null!=gform.hooks[o][r]&&(e=(e=gform.hooks[o][r]).filter(function(o,r,e){return!!(null!=n&&n!=o.tag||null!=t&&t!=o.priority)}),gform.hooks[o][r]=e)}});\n\/* ]]> *\/\n<\/script>\n\n                <div class='gf_browser_gecko gform_wrapper gravity-theme gform-theme--no-framework' data-form-theme='gravity-theme' data-form-index='0' id='gform_wrapper_17' style='display:none'><div id='gf_17' class='gform_anchor' tabindex='-1'><\/div><form method='post' enctype='multipart\/form-data' target='gform_ajax_frame_17' id='gform_17'  action='\/dialog\/wp-json\/wp\/v2\/pages\/27#gf_17' data-formid='17' novalidate>\n        <div id='gf_progressbar_wrapper_17' class='gf_progressbar_wrapper' data-start-at-zero=''>\n        \t<p class=\"gf_progressbar_title\">Schritt <span class='gf_step_current_page'>1<\/span> von <span class='gf_step_page_count'>16<\/span><span class='gf_step_page_name'> - Einf\u00fchrung<\/span>\n        \t<\/p>\n            <div class='gf_progressbar gf_progressbar_blue' aria-hidden='true'>\n                <div class='gf_progressbar_percentage percentbar_blue percentbar_6' style='width:6%;'><span>6%<\/span><\/div>\n            <\/div><\/div>\n                        <div class='gform-body gform_body'><div id='gform_page_17_1' class='gform_page ' data-js='page-field-id-0' >\n\t\t\t\t\t<div class='gform_page_fields'><div id='gform_fields_17' class='gform_fields top_label form_sublabel_below description_below validation_below'><div id=\"field_17_4\" class=\"gfield gfield--type-html gfield--width-full gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h4>Einf\u00fchrung<\/h4><\/div><fieldset id=\"field_17_66\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >An welchen Leistungen h\u00e4tten Sie Interesse? Bitte w\u00e4hlen Sie eine oder mehrere Kategorien. (Mehrfachnennung m\u00f6glich)<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(erforderlich)<\/span><\/span><\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_17_66'><div class='gchoice gchoice_17_66_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_66.1' type='checkbox'  value='Unterst\u00fctzung bei der K\u00f6rperpflege'  id='choice_17_66_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_17_66_1' id='label_17_66_1' class='gform-field-label gform-field-label--type-inline'>Unterst\u00fctzung bei der K\u00f6rperpflege<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_17_66_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_66.2' type='checkbox'  value='Entlastung im Alltag'  id='choice_17_66_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_17_66_2' id='label_17_66_2' class='gform-field-label gform-field-label--type-inline'>Entlastung im Alltag<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_17_66_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_66.3' type='checkbox'  value='Begleitung demenziell Erkrankter'  id='choice_17_66_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_17_66_3' id='label_17_66_3' class='gform-field-label gform-field-label--type-inline'>Begleitung demenziell Erkrankter<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><\/div>\n                    <\/div>\n                    <div class='gform-page-footer gform_page_footer top_label'>\n                         <input type='button' id='gform_next_button_17_3' class='gform_next_button gform-theme-button button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='next' value='Weiter'  \/> \n                    <\/div>\n                <\/div>\n                <div id='gform_page_17_2' class='gform_page' data-js='page-field-id-3' style='display:none;'>\n                    <div class='gform_page_fields'>\n                        <div id='gform_fields_17_2' class='gform_fields top_label form_sublabel_below description_below validation_below'><div id=\"field_17_6\" class=\"gfield gfield--type-html gfield--width-full gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h4>Unterst\u00fctzung bei der K\u00f6rperpflege<\/h4><\/div><fieldset id=\"field_17_5\" class=\"gfield gfield--type-radio gfield--type-choice gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Wie oft soll die zu pflegende Person pro Woche geduscht, gewaschen oder gebadet werden?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(erforderlich)<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_17_5'>\n\t\t\t<div class='gchoice gchoice_17_5_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_5' type='radio' value='1 x pro Woche'  id='choice_17_5_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_17_5_0' id='label_17_5_0' class='gform-field-label gform-field-label--type-inline'>1 x pro Woche<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_17_5_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_5' type='radio' value='2 x pro Woche'  id='choice_17_5_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_17_5_1' id='label_17_5_1' class='gform-field-label gform-field-label--type-inline'>2 x pro Woche<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_17_5_2'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_5' type='radio' value='3 x pro Woche'  id='choice_17_5_2' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_17_5_2' id='label_17_5_2' class='gform-field-label gform-field-label--type-inline'>3 x pro Woche<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_17_5_3'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_5' type='radio' value='t\u00e4glich'  id='choice_17_5_3' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_17_5_3' id='label_17_5_3' class='gform-field-label gform-field-label--type-inline'>t\u00e4glich<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_17_5_4'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_5' type='radio' value='keine Angaben'  id='choice_17_5_4' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_17_5_4' id='label_17_5_4' class='gform-field-label gform-field-label--type-inline'>keine Angaben<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><\/div>\n                    <\/div>\n                    <div class='gform-page-footer gform_page_footer top_label'>\n                        <input type='button' id='gform_previous_button_17_9' class='gform_previous_button gform-theme-button gform-theme-button--secondary button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='previous' value='Zur\u00fcck'  \/> <input type='button' id='gform_next_button_17_9' class='gform_next_button gform-theme-button button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='next' value='Weiter'  \/> \n                    <\/div>\n                <\/div>\n                <div id='gform_page_17_3' class='gform_page' data-js='page-field-id-9' style='display:none;'>\n                    <div class='gform_page_fields'>\n                        <div id='gform_fields_17_3' class='gform_fields top_label form_sublabel_below description_below validation_below'><div id=\"field_17_20\" class=\"gfield gfield--type-html gfield--width-full gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h4>Unterst\u00fctzung bei der K\u00f6rperpflege<\/h4><\/div><fieldset id=\"field_17_21\" class=\"gfield gfield--type-radio gfield--type-choice gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Wie oft schaffen Sie es pro Woche, die zu pflegende Person stressfrei zu duschen, waschen oder baden?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(erforderlich)<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_17_21'>\n\t\t\t<div class='gchoice gchoice_17_21_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_21' type='radio' value='1 x pro Woche'  id='choice_17_21_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_17_21_0' id='label_17_21_0' class='gform-field-label gform-field-label--type-inline'>1 x pro Woche<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_17_21_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_21' type='radio' value='2 x pro Woche'  id='choice_17_21_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_17_21_1' id='label_17_21_1' class='gform-field-label gform-field-label--type-inline'>2 x pro Woche<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_17_21_2'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_21' type='radio' value='3 x pro Woche'  id='choice_17_21_2' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_17_21_2' id='label_17_21_2' class='gform-field-label gform-field-label--type-inline'>3 x pro Woche<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_17_21_3'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_21' type='radio' value='t\u00e4glich'  id='choice_17_21_3' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_17_21_3' id='label_17_21_3' class='gform-field-label gform-field-label--type-inline'>t\u00e4glich<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_17_21_4'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_21' type='radio' value='keine Angaben'  id='choice_17_21_4' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_17_21_4' id='label_17_21_4' class='gform-field-label gform-field-label--type-inline'>keine Angaben<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><\/div>\n                    <\/div>\n                    <div class='gform-page-footer gform_page_footer top_label'>\n                        <input type='button' id='gform_previous_button_17_19' class='gform_previous_button gform-theme-button gform-theme-button--secondary button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='previous' value='Zur\u00fcck'  \/> <input type='button' id='gform_next_button_17_19' class='gform_next_button gform-theme-button button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='next' value='Weiter'  \/> \n                    <\/div>\n                <\/div>\n                <div id='gform_page_17_4' class='gform_page' data-js='page-field-id-19' style='display:none;'>\n                    <div class='gform_page_fields'>\n                        <div id='gform_fields_17_4' class='gform_fields top_label form_sublabel_below description_below validation_below'><div id=\"field_17_7\" class=\"gfield gfield--type-html gfield--width-full gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h4>Unterst\u00fctzung bei der K\u00f6rperpflege<\/h4><\/div><fieldset id=\"field_17_8\" class=\"gfield gfield--type-radio gfield--type-choice gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Haben Sie schon Unterst\u00fctzung bei der K\u00f6rperpflege in Anspruch genommen?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(erforderlich)<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_17_8'>\n\t\t\t<div class='gchoice gchoice_17_8_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_8' type='radio' value='ja'  id='choice_17_8_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_17_8_0' id='label_17_8_0' class='gform-field-label gform-field-label--type-inline'>ja<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_17_8_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_8' type='radio' value='nein'  id='choice_17_8_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_17_8_1' id='label_17_8_1' class='gform-field-label gform-field-label--type-inline'>nein<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_17_8_2'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_8' type='radio' value='keine Angaben'  id='choice_17_8_2' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_17_8_2' id='label_17_8_2' class='gform-field-label gform-field-label--type-inline'>keine Angaben<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><\/div>\n                    <\/div>\n                    <div class='gform-page-footer gform_page_footer top_label'>\n                        <input type='button' id='gform_previous_button_17_10' class='gform_previous_button gform-theme-button gform-theme-button--secondary button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='previous' value='Zur\u00fcck'  \/> <input type='button' id='gform_next_button_17_10' class='gform_next_button gform-theme-button button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='next' value='Weiter'  \/> \n                    <\/div>\n                <\/div>\n                <div id='gform_page_17_5' class='gform_page' data-js='page-field-id-10' style='display:none;'>\n                    <div class='gform_page_fields'>\n                        <div id='gform_fields_17_5' class='gform_fields top_label form_sublabel_below description_below validation_below'><div id=\"field_17_11\" class=\"gfield gfield--type-html gfield--width-full gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h4>Unterst\u00fctzung bei der K\u00f6rperpflege<\/h4><\/div><fieldset id=\"field_17_12\" class=\"gfield gfield--type-radio gfield--type-choice gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Waren Sie mit der Unterst\u00fctzung in der K\u00f6rperpflege zufrieden?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(erforderlich)<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_17_12'>\n\t\t\t<div class='gchoice gchoice_17_12_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_12' type='radio' value='ja'  id='choice_17_12_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_17_12_0' id='label_17_12_0' class='gform-field-label gform-field-label--type-inline'>ja<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_17_12_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_12' type='radio' value='nein'  id='choice_17_12_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_17_12_1' id='label_17_12_1' class='gform-field-label gform-field-label--type-inline'>nein<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_17_12_2'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_12' type='radio' value='manchmal'  id='choice_17_12_2' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_17_12_2' id='label_17_12_2' class='gform-field-label gform-field-label--type-inline'>manchmal<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_17_12_3'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_12' type='radio' value='keine Angaben'  id='choice_17_12_3' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_17_12_3' id='label_17_12_3' class='gform-field-label gform-field-label--type-inline'>keine Angaben<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_17_69\" class=\"gfield gfield--type-text gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_17_69'>Bitte nennen Sie uns den Grund der Unzufriedenheit (optional)<\/label><div class='ginput_container ginput_container_text'><input name='input_69' id='input_17_69' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><\/div>\n                    <\/div>\n                    <div class='gform-page-footer gform_page_footer top_label'>\n                        <input type='button' id='gform_previous_button_17_39' class='gform_previous_button gform-theme-button gform-theme-button--secondary button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='previous' value='Zur\u00fcck'  \/> <input type='button' id='gform_next_button_17_39' class='gform_next_button gform-theme-button button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='next' value='Weiter'  \/> \n                    <\/div>\n                <\/div>\n                <div id='gform_page_17_6' class='gform_page' data-js='page-field-id-39' style='display:none;'>\n                    <div class='gform_page_fields'>\n                        <div id='gform_fields_17_6' class='gform_fields top_label form_sublabel_below description_below validation_below'><div id=\"field_17_40\" class=\"gfield gfield--type-html gfield--width-full gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h4>Entlastung im Alltag<\/h4><\/div><fieldset id=\"field_17_41\" class=\"gfield gfield--type-radio gfield--type-choice gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Wie oft nehmen Sie sich Zeit f\u00fcr sich selbst?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(erforderlich)<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_17_41'>\n\t\t\t<div class='gchoice gchoice_17_41_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_41' type='radio' value='nie'  id='choice_17_41_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_17_41_0' id='label_17_41_0' class='gform-field-label gform-field-label--type-inline'>nie<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_17_41_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_41' type='radio' value='sehr selten (weniger als 1 \u2013 2 mal im Monat)'  id='choice_17_41_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_17_41_1' id='label_17_41_1' class='gform-field-label gform-field-label--type-inline'>sehr selten (weniger als 1 \u2013 2 mal im Monat)<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_17_41_2'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_41' type='radio' value='selten (1 \u2013 2 mal im Monat)'  id='choice_17_41_2' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_17_41_2' id='label_17_41_2' class='gform-field-label gform-field-label--type-inline'>selten (1 \u2013 2 mal im Monat)<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_17_41_3'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_41' type='radio' value='regelm\u00e4\u00dfig (mehrmals in der Woche)'  id='choice_17_41_3' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_17_41_3' id='label_17_41_3' class='gform-field-label gform-field-label--type-inline'>regelm\u00e4\u00dfig (mehrmals in der Woche)<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_17_41_4'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_41' type='radio' value='keine Angaben'  id='choice_17_41_4' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_17_41_4' id='label_17_41_4' class='gform-field-label gform-field-label--type-inline'>keine Angaben<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><\/div>\n                    <\/div>\n                    <div class='gform-page-footer gform_page_footer top_label'>\n                        <input type='button' id='gform_previous_button_17_42' class='gform_previous_button gform-theme-button gform-theme-button--secondary button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='previous' value='Zur\u00fcck'  \/> <input type='button' id='gform_next_button_17_42' class='gform_next_button gform-theme-button button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='next' value='Weiter'  \/> \n                    <\/div>\n                <\/div>\n                <div id='gform_page_17_7' class='gform_page' data-js='page-field-id-42' style='display:none;'>\n                    <div class='gform_page_fields'>\n                        <div id='gform_fields_17_7' class='gform_fields top_label form_sublabel_below description_below validation_below'><div id=\"field_17_44\" class=\"gfield gfield--type-html gfield--width-full gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h4>Entlastung im Alltag<\/h4><\/div><fieldset id=\"field_17_43\" class=\"gfield gfield--type-radio gfield--type-choice gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Haben Sie noch Zeit f\u00fcr Ihre Hobbies?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(erforderlich)<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_17_43'>\n\t\t\t<div class='gchoice gchoice_17_43_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_43' type='radio' value='ja'  id='choice_17_43_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_17_43_0' id='label_17_43_0' class='gform-field-label gform-field-label--type-inline'>ja<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_17_43_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_43' type='radio' value='nein'  id='choice_17_43_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_17_43_1' id='label_17_43_1' class='gform-field-label gform-field-label--type-inline'>nein<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_17_43_2'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_43' type='radio' value='gelegentlich'  id='choice_17_43_2' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_17_43_2' id='label_17_43_2' class='gform-field-label gform-field-label--type-inline'>gelegentlich<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_17_43_3'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_43' type='radio' value='keine Angaben'  id='choice_17_43_3' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_17_43_3' id='label_17_43_3' class='gform-field-label gform-field-label--type-inline'>keine Angaben<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><\/div>\n                    <\/div>\n                    <div class='gform-page-footer gform_page_footer top_label'>\n                        <input type='button' id='gform_previous_button_17_45' class='gform_previous_button gform-theme-button gform-theme-button--secondary button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='previous' value='Zur\u00fcck'  \/> <input type='button' id='gform_next_button_17_45' class='gform_next_button gform-theme-button button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='next' value='Weiter'  \/> \n                    <\/div>\n                <\/div>\n                <div id='gform_page_17_8' class='gform_page' data-js='page-field-id-45' style='display:none;'>\n                    <div class='gform_page_fields'>\n                        <div id='gform_fields_17_8' class='gform_fields top_label form_sublabel_below description_below validation_below'><div id=\"field_17_46\" class=\"gfield gfield--type-html gfield--width-full gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h4>Entlastung im Alltag<\/h4><\/div><fieldset id=\"field_17_47\" class=\"gfield gfield--type-radio gfield--type-choice gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Wie oft k\u00f6nnen Sie unbeschwerte Momente mit der zu pflegenden Person genie\u00dfen?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(erforderlich)<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_17_47'>\n\t\t\t<div class='gchoice gchoice_17_47_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_47' type='radio' value='nie'  id='choice_17_47_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_17_47_0' id='label_17_47_0' class='gform-field-label gform-field-label--type-inline'>nie<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_17_47_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_47' type='radio' value='sehr selten (1 \u2013 2 mal im Jahr)'  id='choice_17_47_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_17_47_1' id='label_17_47_1' class='gform-field-label gform-field-label--type-inline'>sehr selten (1 \u2013 2 mal im Jahr)<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_17_47_2'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_47' type='radio' value='selten (mehrmals im Jahr)'  id='choice_17_47_2' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_17_47_2' id='label_17_47_2' class='gform-field-label gform-field-label--type-inline'>selten (mehrmals im Jahr)<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_17_47_3'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_47' type='radio' value='regelm\u00e4\u00dfig (1 \u2013 2 mal im Monat)'  id='choice_17_47_3' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_17_47_3' id='label_17_47_3' class='gform-field-label gform-field-label--type-inline'>regelm\u00e4\u00dfig (1 \u2013 2 mal im Monat)<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_17_47_4'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_47' type='radio' value='h\u00e4ufig (mehrmals in der Woche)'  id='choice_17_47_4' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_17_47_4' id='label_17_47_4' class='gform-field-label gform-field-label--type-inline'>h\u00e4ufig (mehrmals in der Woche)<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_17_47_5'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_47' type='radio' value='keine Angaben'  id='choice_17_47_5' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_17_47_5' id='label_17_47_5' class='gform-field-label gform-field-label--type-inline'>keine Angaben<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><\/div>\n                    <\/div>\n                    <div class='gform-page-footer gform_page_footer top_label'>\n                        <input type='button' id='gform_previous_button_17_48' class='gform_previous_button gform-theme-button gform-theme-button--secondary button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='previous' value='Zur\u00fcck'  \/> <input type='button' id='gform_next_button_17_48' class='gform_next_button gform-theme-button button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='next' value='Weiter'  \/> \n                    <\/div>\n                <\/div>\n                <div id='gform_page_17_9' class='gform_page' data-js='page-field-id-48' style='display:none;'>\n                    <div class='gform_page_fields'>\n                        <div id='gform_fields_17_9' class='gform_fields top_label form_sublabel_below description_below validation_below'><div id=\"field_17_51\" class=\"gfield gfield--type-html gfield--width-full gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h4>Entlastung im Alltag<\/h4><\/div><fieldset id=\"field_17_50\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Welche Art von Unterst\u00fctzung bei der zu pflegenden Person k\u00f6nnen Sie ohne Zeitdruck selbst leisten? (Mehrfachnennung m\u00f6glich)<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(erforderlich)<\/span><\/span><\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_17_50'><div class='gchoice gchoice_17_50_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_50.1' type='checkbox'  value='Einkaufen'  id='choice_17_50_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_17_50_1' id='label_17_50_1' class='gform-field-label gform-field-label--type-inline'>Einkaufen<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_17_50_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_50.2' type='checkbox'  value='Spazierengehen'  id='choice_17_50_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_17_50_2' id='label_17_50_2' class='gform-field-label gform-field-label--type-inline'>Spazierengehen<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_17_50_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_50.3' type='checkbox'  value='Gespr\u00e4che f\u00fchren'  id='choice_17_50_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_17_50_3' id='label_17_50_3' class='gform-field-label gform-field-label--type-inline'>Gespr\u00e4che f\u00fchren<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_17_50_4'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_50.4' type='checkbox'  value='Gemeinsam kochen'  id='choice_17_50_4'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_17_50_4' id='label_17_50_4' class='gform-field-label gform-field-label--type-inline'>Gemeinsam kochen<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_17_50_5'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_50.5' type='checkbox'  value='Hobbies ausf\u00fchren'  id='choice_17_50_5'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_17_50_5' id='label_17_50_5' class='gform-field-label gform-field-label--type-inline'>Hobbies ausf\u00fchren<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_17_50_6'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_50.6' type='checkbox'  value='Begleitung zum Arzt'  id='choice_17_50_6'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_17_50_6' id='label_17_50_6' class='gform-field-label gform-field-label--type-inline'>Begleitung zum Arzt<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_17_50_7'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_50.7' type='checkbox'  value='Sicherheit durch Anwesenheit bieten'  id='choice_17_50_7'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_17_50_7' id='label_17_50_7' class='gform-field-label gform-field-label--type-inline'>Sicherheit durch Anwesenheit bieten<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_17_50_8'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_50.8' type='checkbox'  value='keine Angaben'  id='choice_17_50_8'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_17_50_8' id='label_17_50_8' class='gform-field-label gform-field-label--type-inline'>keine Angaben<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><\/div>\n                    <\/div>\n                    <div class='gform-page-footer gform_page_footer top_label'>\n                        <input type='button' id='gform_previous_button_17_53' class='gform_previous_button gform-theme-button gform-theme-button--secondary button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='previous' value='Zur\u00fcck'  \/> <input type='button' id='gform_next_button_17_53' class='gform_next_button gform-theme-button button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='next' value='Weiter'  \/> \n                    <\/div>\n                <\/div>\n                <div id='gform_page_17_10' class='gform_page' data-js='page-field-id-53' style='display:none;'>\n                    <div class='gform_page_fields'>\n                        <div id='gform_fields_17_10' class='gform_fields top_label form_sublabel_below description_below validation_below'><div id=\"field_17_55\" class=\"gfield gfield--type-html gfield--width-full gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h4>Begleitung demenziell Erkrankter<\/h4><\/div><fieldset id=\"field_17_56\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Welche Beeintr\u00e4chtigungen hat die demenziell erkrankte Person? (Mehrfachnennung m\u00f6glich)<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(erforderlich)<\/span><\/span><\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_17_56'><div class='gchoice gchoice_17_56_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_56.1' type='checkbox'  value='erkennt mich nicht mehr'  id='choice_17_56_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_17_56_1' id='label_17_56_1' class='gform-field-label gform-field-label--type-inline'>erkennt mich nicht mehr<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_17_56_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_56.2' type='checkbox'  value='Umkehr des Tag-Nacht-Rhythmus'  id='choice_17_56_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_17_56_2' id='label_17_56_2' class='gform-field-label gform-field-label--type-inline'>Umkehr des Tag-Nacht-Rhythmus<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_17_56_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_56.3' type='checkbox'  value='Hinlauftendenz'  id='choice_17_56_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_17_56_3' id='label_17_56_3' class='gform-field-label gform-field-label--type-inline'>Hinlauftendenz<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_17_56_4'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_56.4' type='checkbox'  value='Aggressivit\u00e4t'  id='choice_17_56_4'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_17_56_4' id='label_17_56_4' class='gform-field-label gform-field-label--type-inline'>Aggressivit\u00e4t<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_17_56_5'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_56.5' type='checkbox'  value='Orientierungsprobleme'  id='choice_17_56_5'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_17_56_5' id='label_17_56_5' class='gform-field-label gform-field-label--type-inline'>Orientierungsprobleme<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_17_56_6'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_56.6' type='checkbox'  value='keine Angaben'  id='choice_17_56_6'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_17_56_6' id='label_17_56_6' class='gform-field-label gform-field-label--type-inline'>keine Angaben<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><\/div>\n                    <\/div>\n                    <div class='gform-page-footer gform_page_footer top_label'>\n                        <input type='button' id='gform_previous_button_17_57' class='gform_previous_button gform-theme-button gform-theme-button--secondary button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='previous' value='Zur\u00fcck'  \/> <input type='button' id='gform_next_button_17_57' class='gform_next_button gform-theme-button button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='next' value='Weiter'  \/> \n                    <\/div>\n                <\/div>\n                <div id='gform_page_17_11' class='gform_page' data-js='page-field-id-57' style='display:none;'>\n                    <div class='gform_page_fields'>\n                        <div id='gform_fields_17_11' class='gform_fields top_label form_sublabel_below description_below validation_below'><div id=\"field_17_58\" class=\"gfield gfield--type-html gfield--width-full gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h4>Begleitung demenziell Erkrankter<\/h4><\/div><fieldset id=\"field_17_59\" class=\"gfield gfield--type-radio gfield--type-choice gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Wie viele Stunden pro Tag sind Sie in die Betreuung eingebunden?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(erforderlich)<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_17_59'>\n\t\t\t<div class='gchoice gchoice_17_59_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_59' type='radio' value='bis zu 2 Stunden am Tag'  id='choice_17_59_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_17_59_0' id='label_17_59_0' class='gform-field-label gform-field-label--type-inline'>bis zu 2 Stunden am Tag<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_17_59_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_59' type='radio' value='2 \u2013 4 Stunden am Tag'  id='choice_17_59_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_17_59_1' id='label_17_59_1' class='gform-field-label gform-field-label--type-inline'>2 \u2013 4 Stunden am Tag<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_17_59_2'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_59' type='radio' value='mehr als 4 Stunden am Tag'  id='choice_17_59_2' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_17_59_2' id='label_17_59_2' class='gform-field-label gform-field-label--type-inline'>mehr als 4 Stunden am Tag<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_17_59_3'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_59' type='radio' value='keine Angaben'  id='choice_17_59_3' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_17_59_3' id='label_17_59_3' class='gform-field-label gform-field-label--type-inline'>keine Angaben<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><\/div>\n                    <\/div>\n                    <div class='gform-page-footer gform_page_footer top_label'>\n                        <input type='button' id='gform_previous_button_17_60' class='gform_previous_button gform-theme-button gform-theme-button--secondary button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='previous' value='Zur\u00fcck'  \/> <input type='button' id='gform_next_button_17_60' class='gform_next_button gform-theme-button button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='next' value='Weiter'  \/> \n                    <\/div>\n                <\/div>\n                <div id='gform_page_17_12' class='gform_page' data-js='page-field-id-60' style='display:none;'>\n                    <div class='gform_page_fields'>\n                        <div id='gform_fields_17_12' class='gform_fields top_label form_sublabel_below description_below validation_below'><div id=\"field_17_61\" class=\"gfield gfield--type-html gfield--width-full gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h4>Begleitung demenziell Erkrankter<\/h4><\/div><fieldset id=\"field_17_62\" class=\"gfield gfield--type-radio gfield--type-choice gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Wie empfinden Sie die Betreuung der demenziell erkrankten Person?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(erforderlich)<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_17_62'>\n\t\t\t<div class='gchoice gchoice_17_62_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_62' type='radio' value='entspannt'  id='choice_17_62_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_17_62_0' id='label_17_62_0' class='gform-field-label gform-field-label--type-inline'>entspannt<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_17_62_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_62' type='radio' value='herausfordernd'  id='choice_17_62_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_17_62_1' id='label_17_62_1' class='gform-field-label gform-field-label--type-inline'>herausfordernd<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_17_62_2'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_62' type='radio' value='stressig'  id='choice_17_62_2' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_17_62_2' id='label_17_62_2' class='gform-field-label gform-field-label--type-inline'>stressig<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_17_62_3'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_62' type='radio' value='\u00fcberfordernd'  id='choice_17_62_3' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_17_62_3' id='label_17_62_3' class='gform-field-label gform-field-label--type-inline'>\u00fcberfordernd<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_17_62_4'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_62' type='radio' value='keine Angaben'  id='choice_17_62_4' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_17_62_4' id='label_17_62_4' class='gform-field-label gform-field-label--type-inline'>keine Angaben<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><\/div>\n                    <\/div>\n                    <div class='gform-page-footer gform_page_footer top_label'>\n                        <input type='button' id='gform_previous_button_17_63' class='gform_previous_button gform-theme-button gform-theme-button--secondary button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='previous' value='Zur\u00fcck'  \/> <input type='button' id='gform_next_button_17_63' class='gform_next_button gform-theme-button button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='next' value='Weiter'  \/> \n                    <\/div>\n                <\/div>\n                <div id='gform_page_17_13' class='gform_page' data-js='page-field-id-63' style='display:none;'>\n                    <div class='gform_page_fields'>\n                        <div id='gform_fields_17_13' class='gform_fields top_label form_sublabel_below description_below validation_below'><div id=\"field_17_64\" class=\"gfield gfield--type-html gfield--width-full gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h4>Begleitung demenziell Erkrankter<\/h4><\/div><fieldset id=\"field_17_65\" class=\"gfield gfield--type-radio gfield--type-choice gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Wie oft nehmen Sie sich Zeit f\u00fcr sich selbst?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(erforderlich)<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_17_65'>\n\t\t\t<div class='gchoice gchoice_17_65_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_65' type='radio' value='nie'  id='choice_17_65_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_17_65_0' id='label_17_65_0' class='gform-field-label gform-field-label--type-inline'>nie<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_17_65_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_65' type='radio' value='sehr selten (weniger als 1 \u2013 2 mal im Monat)'  id='choice_17_65_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_17_65_1' id='label_17_65_1' class='gform-field-label gform-field-label--type-inline'>sehr selten (weniger als 1 \u2013 2 mal im Monat)<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_17_65_2'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_65' type='radio' value='selten (1 \u2013 2 mal im Monat)'  id='choice_17_65_2' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_17_65_2' id='label_17_65_2' class='gform-field-label gform-field-label--type-inline'>selten (1 \u2013 2 mal im Monat)<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_17_65_3'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_65' type='radio' value='regelm\u00e4\u00dfig (mehrmals in der Woche)'  id='choice_17_65_3' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_17_65_3' id='label_17_65_3' class='gform-field-label gform-field-label--type-inline'>regelm\u00e4\u00dfig (mehrmals in der Woche)<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_17_65_4'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_65' type='radio' value='keine Angaben'  id='choice_17_65_4' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_17_65_4' id='label_17_65_4' class='gform-field-label gform-field-label--type-inline'>keine Angaben<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><\/div>\n                    <\/div>\n                    <div class='gform-page-footer gform_page_footer top_label'>\n                        <input type='button' id='gform_previous_button_17_67' class='gform_previous_button gform-theme-button gform-theme-button--secondary button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='previous' value='Zur\u00fcck'  \/> <input type='button' id='gform_next_button_17_67' class='gform_next_button gform-theme-button button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='next' value='Weiter'  \/> \n                    <\/div>\n                <\/div>\n                <div id='gform_page_17_14' class='gform_page' data-js='page-field-id-67' style='display:none;'>\n                    <div class='gform_page_fields'>\n                        <div id='gform_fields_17_14' class='gform_fields top_label form_sublabel_below description_below validation_below'><fieldset id=\"field_17_18\" class=\"gfield gfield--type-radio gfield--type-choice gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Wie viele Stunden soll der\/die Home Instead Mitarbeitende sich f\u00fcr die zu pflegende Person pro Woche Zeit nehmen?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(erforderlich)<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_17_18'>\n\t\t\t<div class='gchoice gchoice_17_18_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_18' type='radio' value='bis zu 1 Stunde'  id='choice_17_18_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_17_18_0' id='label_17_18_0' class='gform-field-label gform-field-label--type-inline'>bis zu 1 Stunde<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_17_18_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_18' type='radio' value='1 \u2013 2 Stunden'  id='choice_17_18_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_17_18_1' id='label_17_18_1' class='gform-field-label gform-field-label--type-inline'>1 \u2013 2 Stunden<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_17_18_2'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_18' type='radio' value='2 \u2013 4 Stunden'  id='choice_17_18_2' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_17_18_2' id='label_17_18_2' class='gform-field-label gform-field-label--type-inline'>2 \u2013 4 Stunden<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_17_18_3'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_18' type='radio' value='mehr als 4 Stunden'  id='choice_17_18_3' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_17_18_3' id='label_17_18_3' class='gform-field-label gform-field-label--type-inline'>mehr als 4 Stunden<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_17_18_4'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_18' type='radio' value='keine Angaben'  id='choice_17_18_4' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_17_18_4' id='label_17_18_4' class='gform-field-label gform-field-label--type-inline'>keine Angaben<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><\/div>\n                    <\/div>\n                    <div class='gform-page-footer gform_page_footer top_label'>\n                        <input type='button' id='gform_previous_button_17_79' class='gform_previous_button gform-theme-button gform-theme-button--secondary button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='previous' value='Zur\u00fcck'  \/> <input type='button' id='gform_next_button_17_79' class='gform_next_button gform-theme-button button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='next' value='Weiter'  \/> \n                    <\/div>\n                <\/div>\n                <div id='gform_page_17_15' class='gform_page' data-js='page-field-id-79' style='display:none;'>\n                    <div class='gform_page_fields'>\n                        <div id='gform_fields_17_15' class='gform_fields top_label form_sublabel_below description_below validation_below'><fieldset id=\"field_17_25\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_hidden\"  ><div class=\"admin-hidden-markup\"><i class=\"gform-icon gform-icon--hidden\" aria-hidden=\"true\" title=\"Dieses Feld wird bei der Anzeige des Formulars ausgeblendet\"><\/i><span>Dieses Feld wird bei der Anzeige des Formulars ausgeblendet<\/span><\/div><legend class='gfield_label gform-field-label gfield_label_before_complex' >Zu welchen Tageszeiten ben\u00f6tigen Sie die Unterst\u00fctzung? (Mehrfachnennung m\u00f6glich)<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(erforderlich)<\/span><\/span><\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_17_25'><div class='gchoice gchoice_17_25_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_25.1' type='checkbox'  value='vormittags'  id='choice_17_25_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_17_25_1' id='label_17_25_1' class='gform-field-label gform-field-label--type-inline'>vormittags<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_17_25_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_25.2' type='checkbox'  value='mittags'  id='choice_17_25_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_17_25_2' id='label_17_25_2' class='gform-field-label gform-field-label--type-inline'>mittags<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_17_25_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_25.3' type='checkbox'  value='abends'  id='choice_17_25_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_17_25_3' id='label_17_25_3' class='gform-field-label gform-field-label--type-inline'>abends<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_17_25_4'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_25.4' type='checkbox'  value='nachts'  id='choice_17_25_4'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_17_25_4' id='label_17_25_4' class='gform-field-label gform-field-label--type-inline'>nachts<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_17_25_5'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_25.5' type='checkbox'  value='keine Angaben'  id='choice_17_25_5'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_17_25_5' id='label_17_25_5' class='gform-field-label gform-field-label--type-inline'>keine Angaben<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_17_28\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_hidden\"  ><div class=\"admin-hidden-markup\"><i class=\"gform-icon gform-icon--hidden\" aria-hidden=\"true\" title=\"Dieses Feld wird bei der Anzeige des Formulars ausgeblendet\"><\/i><span>Dieses Feld wird bei der Anzeige des Formulars ausgeblendet<\/span><\/div><legend class='gfield_label gform-field-label gfield_label_before_complex' >An welchem Tag ist ein Einsatz grunds\u00e4tzlich nicht m\u00f6glich? (Mehrfachnennung m\u00f6glich)<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(erforderlich)<\/span><\/span><\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_17_28'><div class='gchoice gchoice_17_28_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_28.1' type='checkbox'  value='Montag'  id='choice_17_28_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_17_28_1' id='label_17_28_1' class='gform-field-label gform-field-label--type-inline'>Montag<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_17_28_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_28.2' type='checkbox'  value='Dienstag'  id='choice_17_28_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_17_28_2' id='label_17_28_2' class='gform-field-label gform-field-label--type-inline'>Dienstag<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_17_28_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_28.3' type='checkbox'  value='Mittwoch'  id='choice_17_28_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_17_28_3' id='label_17_28_3' class='gform-field-label gform-field-label--type-inline'>Mittwoch<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_17_28_4'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_28.4' type='checkbox'  value='Donnerstag'  id='choice_17_28_4'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_17_28_4' id='label_17_28_4' class='gform-field-label gform-field-label--type-inline'>Donnerstag<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_17_28_5'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_28.5' type='checkbox'  value='Freitag'  id='choice_17_28_5'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_17_28_5' id='label_17_28_5' class='gform-field-label gform-field-label--type-inline'>Freitag<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_17_28_6'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_28.6' type='checkbox'  value='Samstag'  id='choice_17_28_6'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_17_28_6' id='label_17_28_6' class='gform-field-label gform-field-label--type-inline'>Samstag<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_17_28_7'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_28.7' type='checkbox'  value='Sonntag'  id='choice_17_28_7'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_17_28_7' id='label_17_28_7' class='gform-field-label gform-field-label--type-inline'>Sonntag<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_17_28_8'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_28.8' type='checkbox'  value='keine Angaben'  id='choice_17_28_8'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_17_28_8' id='label_17_28_8' class='gform-field-label gform-field-label--type-inline'>keine Angaben<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_17_32\" class=\"gfield gfield--type-radio gfield--type-choice gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Welchen Pflegegrad hat die zu pflegende Person?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(erforderlich)<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_17_32'>\n\t\t\t<div class='gchoice gchoice_17_32_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_32' type='radio' value='keinen'  id='choice_17_32_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_17_32_0' id='label_17_32_0' class='gform-field-label gform-field-label--type-inline'>keinen<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_17_32_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_32' type='radio' value='1'  id='choice_17_32_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_17_32_1' id='label_17_32_1' class='gform-field-label gform-field-label--type-inline'>1<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_17_32_2'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_32' type='radio' value='2'  id='choice_17_32_2' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_17_32_2' id='label_17_32_2' class='gform-field-label gform-field-label--type-inline'>2<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_17_32_3'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_32' type='radio' value='3'  id='choice_17_32_3' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_17_32_3' id='label_17_32_3' class='gform-field-label gform-field-label--type-inline'>3<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_17_32_4'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_32' type='radio' value='4'  id='choice_17_32_4' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_17_32_4' id='label_17_32_4' class='gform-field-label gform-field-label--type-inline'>4<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_17_32_5'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_32' type='radio' value='5'  id='choice_17_32_5' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_17_32_5' id='label_17_32_5' class='gform-field-label gform-field-label--type-inline'>5<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_17_32_6'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_32' type='radio' value='ist beantragt'  id='choice_17_32_6' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_17_32_6' id='label_17_32_6' class='gform-field-label gform-field-label--type-inline'>ist beantragt<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_17_32_7'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_32' type='radio' value='keine Angaben'  id='choice_17_32_7' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_17_32_7' id='label_17_32_7' class='gform-field-label gform-field-label--type-inline'>keine Angaben<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_17_35\" class=\"gfield gfield--type-radio gfield--type-choice gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_hidden\"  ><div class=\"admin-hidden-markup\"><i class=\"gform-icon gform-icon--hidden\" aria-hidden=\"true\" title=\"Dieses Feld wird bei der Anzeige des Formulars ausgeblendet\"><\/i><span>Dieses Feld wird bei der Anzeige des Formulars ausgeblendet<\/span><\/div><legend class='gfield_label gform-field-label' >Stehen die Pflegebudgets der Pflegekasse f\u00fcr eine Unterst\u00fctzungsleistung durch Home Instead \/ Ambulanter Pflegdienst zur Verf\u00fcgung?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(erforderlich)<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_17_35'>\n\t\t\t<div class='gchoice gchoice_17_35_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_35' type='radio' value='ja'  id='choice_17_35_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_17_35_0' id='label_17_35_0' class='gform-field-label gform-field-label--type-inline'>ja<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_17_35_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_35' type='radio' value='nein'  id='choice_17_35_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_17_35_1' id='label_17_35_1' class='gform-field-label gform-field-label--type-inline'>nein<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_17_35_2'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_35' type='radio' value='teilweise'  id='choice_17_35_2' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_17_35_2' id='label_17_35_2' class='gform-field-label gform-field-label--type-inline'>teilweise<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_17_35_3'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_35' type='radio' value='nicht bekannt'  id='choice_17_35_3' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_17_35_3' id='label_17_35_3' class='gform-field-label gform-field-label--type-inline'>nicht bekannt<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_17_35_4'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_35' type='radio' value='keine Angaben'  id='choice_17_35_4' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_17_35_4' id='label_17_35_4' class='gform-field-label gform-field-label--type-inline'>keine Angaben<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><\/div>\n                    <\/div>\n                    <div class='gform-page-footer gform_page_footer top_label'>\n                        <input type='button' id='gform_previous_button_17_71' class='gform_previous_button gform-theme-button gform-theme-button--secondary button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='previous' value='Zur\u00fcck'  \/> <input type='button' id='gform_next_button_17_71' class='gform_next_button gform-theme-button button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='next' value='Weiter'  \/> \n                    <\/div>\n                <\/div>\n                <div id='gform_page_17_16' class='gform_page' data-js='page-field-id-71' style='display:none;'>\n                    <div class='gform_page_fields'>\n                        <div id='gform_fields_17_16' class='gform_fields top_label form_sublabel_below description_below validation_below'><div id=\"field_17_72\" class=\"gfield gfield--type-html gfield--width-full gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h2>Ihre kostenlose und unverbindliche Beratung \u2013 nur einen Klick entfernt.<\/h2>\n<p><strong>Ausgehend von Ihren Angaben m\u00f6chten wir Ihnen individuell angepasste L\u00f6sungen anbieten, die auf die spezifischen Bed\u00fcrfnisse und W\u00fcnsche der zu pflegenden Person zugeschnitten sind, und gemeinsam mit Ihnen einen ma\u00dfgeschneiderten Pflegeplan entwickeln.<\/strong><p>\n<p>Als Dankesch\u00f6n f\u00fcr Ihre Teilnahme an dieser Befragung und das uns entgegengebrachte Vertrauen bieten wir Ihnen ein kostenloses und unverbindliches Erstgespr\u00e4ch an \u2013 direkt vor Ort. Ziel dieses Erstgespr\u00e4ches ist es festzustellen, wie wir mit unserer professionellen Unterst\u00fctzung und Beratung die Lebensqualit\u00e4t der zu pflegenden Person erhalten und verbessern und die Pflege und das t\u00e4gliche Leben f\u00fcr Sie und Ihre Angeh\u00f6rigen erleichtern k\u00f6nnen.<p>\n\n<p><strong>Bitte tragen Sie Ihre Kontaktdaten hier ein, damit wir einen Gespr\u00e4chstermin vereinbaren k\u00f6nnen.<\/strong><\/p><\/div><div id=\"field_17_73\" class=\"gfield gfield--type-text gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below hidden_label field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_17_73'>Vorname<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(erforderlich)<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_73' id='input_17_73' type='text' value='' class='large'    placeholder='Vorname' aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_17_74\" class=\"gfield gfield--type-text gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below hidden_label field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_17_74'>Nachname<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(erforderlich)<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_74' id='input_17_74' type='text' value='' class='large'    placeholder='Nachname' aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_17_75\" class=\"gfield gfield--type-text gfield--width-half gfield_contains_required field_sublabel_below gfield--no-description field_description_below hidden_label field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_17_75'>Telefon<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(erforderlich)<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_75' id='input_17_75' type='text' value='' class='large'    placeholder='Telefon' aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_17_76\" class=\"gfield gfield--type-email gfield--width-half field_sublabel_below gfield--no-description field_description_below hidden_label field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_17_76'>E-Mail-Adresse<\/label><div class='ginput_container ginput_container_email'>\n                            <input name='input_76' id='input_17_76' type='email' value='' class='large'   placeholder='E-Mail-Adresse (optional)'  aria-invalid=\"false\"  \/>\n                        <\/div><\/div><div id=\"field_17_80\" class=\"gfield gfield--type-text gfield--width-full field_sublabel_below gfield--no-description field_description_below hidden_label field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_17_80'>Wann sind Sie am besten zu erreichen?<\/label><div class='ginput_container ginput_container_text'><input name='input_80' id='input_17_80' type='text' value='' class='large'    placeholder='Wann sind Sie am besten zu erreichen? (optional)'  aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_17_78\" class=\"gfield gfield--type-html gfield--width-full gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><p>&nbsp;<\/p><\/div><div id=\"field_17_68\" class=\"gfield gfield--type-text gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_17_68'>Bitte tragen Sie die Postleitzahl des Ortes ein, an dem die Unterst\u00fctzung stattfinden soll.<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(erforderlich)<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_68' id='input_17_68' type='text' value='' class='small'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><fieldset id=\"field_17_77\" class=\"gfield gfield--type-consent gfield--type-choice gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below hidden_label field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Consent<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(erforderlich)<\/span><\/span><\/legend><div class='ginput_container ginput_container_consent'><input name='input_77.1' id='input_17_77_1' type='checkbox' value='1'   aria-required=\"true\" aria-invalid=\"false\"   \/> <label class=\"gform-field-label gform-field-label--type-inline gfield_consent_label\" for='input_17_77_1' >Mit dem Absenden der Anfrage erteilen Sie Home Instead eine Einwilligung, Sie per E-Mail zu kontaktieren. Ihre Einwilligung k\u00f6nnen Sie jederzeit widerrufen. Die Datenschutzbestimmungen der Home Instead habe ich gelesen und akzeptiere diese.<span class=\"gfield_required gfield_required_text\">(erforderlich)<\/span><\/label><input type='hidden' name='input_77.2' value='Mit dem Absenden der Anfrage erteilen Sie Home Instead eine Einwilligung, Sie per E-Mail zu kontaktieren. Ihre Einwilligung k\u00f6nnen Sie jederzeit widerrufen. Die Datenschutzbestimmungen der Home Instead habe ich gelesen und akzeptiere diese.' class='gform_hidden' \/><input type='hidden' name='input_77.3' value='14' class='gform_hidden' \/><\/div><\/fieldset><\/div><\/div>\n        <div class='gform-page-footer gform_page_footer top_label'><input type='submit' id='gform_previous_button_17' class='gform_previous_button gform-theme-button gform-theme-button--secondary button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='previous' value='Zur\u00fcck'  \/> <input type='submit' id='gform_submit_button_17' class='gform_button button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='submit' value='Abschlie\u00dfen'  \/> <input type='hidden' name='gform_ajax' value='form_id=17&amp;title=&amp;description=&amp;tabindex=0&amp;theme=gravity-theme&amp;styles=[]&amp;hash=462367d0d67bda7f413cd8a26b9d702f' \/>\n            <input type='hidden' class='gform_hidden' name='gform_submission_method' 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